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Lynch M, Jones CR. Social prescribing for frequent attenders in primary care: An economic analysis. Front Public Health 2022; 10:902199. [PMID: 36311628 PMCID: PMC9615419 DOI: 10.3389/fpubh.2022.902199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/13/2022] [Indexed: 01/22/2023] Open
Abstract
Background Social prescribing (SP) is a mechanism to link patients with community groups and third sector organizations. It offers a complimentary approach to the traditional medical models to address psychosocial needs of patients more effectively and in turn aims to reduce demand on the NHS. The aim of this study was to explore the economic benefits related to changes in the use of healthcare resources following a social prescribing intervention in four primary care practices in Wales. Methods Quantitative data from routine healthcare usage was collected from the 78 participants pre and post-intervention. The participants were grouped into frequent attenders (FA) (n = 21) and frequent (n = 57) non-attenders (FNA), and a cost analysis was conducted to estimate cost variances based on healthcare unit usage over the length of the pilot intervention. These were then extrapolated forward to identify potential healthcare savings. Results The SP as an intervention generated the largest cost saving for FAs. The cost variance when FAs participated in the intervention shows there is a direct cost saving of £6,113 or £78.37 per participant over the 5 months of the intervention. Conclusions Results suggest there may be a cost saving associated with SP interventions, however caution should be exercised in interpreting the results due to the lack of control group in this study The cost saving were largest for FAs, where the intervention reduced healthcare unit usage as well as actual and inferred impact on associated healthcare costs. This suggests that in practice to generate the maximum cost benefit SP interventions could be targeted at FAs.
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Affiliation(s)
- Mary Lynch
- School of Health and Life Sciences, University of West Scotland, Glasgow, United Kingdom
| | - Ceri R. Jones
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom,*Correspondence: Ceri R. Jones
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Serour M, Al-Weqayyan A, Almazeedi H, Al-Fedhala H, Bahroh A, Aljadi F, AlHilali M. Why parents bring their children with minor health problems to their family practitioners: An unmatched case-control study. J Family Med Prim Care 2021; 10:3725-3731. [PMID: 34934672 PMCID: PMC8653473 DOI: 10.4103/jfmpc.jfmpc_717_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 11/06/2022] Open
Abstract
Background: Parents' of young children who frequently attend primary health care (PHC) services for mild health problems (MHPs) can present a complex and difficult challenge for staff. This phenomenon can expose the child to inappropriate overprescribing, unnecessary medical interventions and may impair the quality of life of parents and children. Aim: To define driving factors for frequent attenders (FAs) preschool children in PHC services in Kuwait. Design and Setting: An unmatched case-control study was conducted in the PHC setting in Kuwait. Method: A sample comprised of 300 parents from 10 PHC centres was selected. The top third children with higher frequency (FAs) visits to their family practitioners (FPs) were compared with the lower third with lower frequency (NFAs) visits to their FPs during the same duration. The Brief Illness Perception Questionnaire (Brief IPQ) was used to assess parents' response to their children's illness. The sociodemographic data for both groups were collected. Culture and background heath status for child and family were collected (order of the child in the family, if the family is living with the extended family and additional help received regarding childcare). The previous medical history of parent, child, and siblings was also included. Results: The mean number of consultations in FAs versus NFAs within the previous year was 15.5 ± 7.6 and 4.3 ± 2.1, respectively. There was no significant difference in means between the two groups of parents in responses to the questions of the adapted Brief IPQ. FAs were more likely to be the first-order child (odds ratio (OR) 2.4; 95% confidence interval (CI) =1.2–4.6), have chronic disease (OR 4.7; 95% CI = 2.1–10.6), and live with the extended family (OR 1.8; 95% CI = 1.1–3.3). They experienced an acute, potentially life-threatening episode previously (OR 2.6; 95% CI = 1.1–6.4), with the same applying to a sibling (OR 72.6; 1.2–6.2) or parent (OR 2.6; CI = 1.1–6.4). Conclusion: Identification of the hidden reasons that affect parents' decisions to consult their FPs frequently for their children's MHPs were important predictors for defining preschool FAs children in the PHC centres and can help the staff provide effective management plans to help them.
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Affiliation(s)
- Maleka Serour
- Research Committee, Kuwait Institute for Medical Specialization, Kuwait
| | - Adnan Al-Weqayyan
- Central Department of Primary Health Care Al Solabeykhat, Kuwait Ministry of Health, Kuwait
| | - Hind Almazeedi
- Abdulla Al Mabark Health Center, Kuwait Ministry of Health, Kuwait
| | - Hanan Al-Fedhala
- Abdulla Al Mabark Health Center, Kuwait Ministry of Health, Kuwait
| | - Ahmed Bahroh
- Abdulla Al Mabark Health Center, Kuwait Ministry of Health, Kuwait
| | - Fatma Aljadi
- Alzahraa Specialty Health Center, Kuwait Ministry of Health, Kuwait
| | - Mohammed AlHilali
- Northern Centre for Cancer Care, Health Education England North East, UK
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Li N, Shou J. Risk factors for the frequent attendance of older patients at community health service centers in China: a cross-sectional study based on stratified sampling. BMC FAMILY PRACTICE 2021; 22:221. [PMID: 34772360 PMCID: PMC8589087 DOI: 10.1186/s12875-021-01575-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022]
Abstract
Background This study aimed to investigate the characteristics of frequent attenders (FAs) among older patients in Shanghai, China, and explore the associated factors. Methods This cross-sectional study was conducted in six community health service centers in Shanghai, China, from August to December 2018 based on stratified sampling. On the basis of our preliminary study, FAs were defined as those attending at least four consultations in a month. A self-administered questionnaire was used to collect the clinicodemographic data of the participants. Social support, pain severity, depression, and anxiety were evaluated using the Social Support Revalued Scale, six-point Behavioral Rating Scale, Patient Health Questionnaire–9, and Generalized Anxiety Disorder Scale, respectively. Results This study included 619 patients aged > 60 years. Among these patients, 155 (25%) were FAs to a community health service center, 366 (59.1%) had 1 or 2 chronic diseases, 179 (28.9%) had ≥3 chronic diseases, 313 (50.4%) opted for a family doctor service, and 537 (86.8%) chose a community health service center for the first consultation. The following were identified as independent risk factors for frequent attendance: widowed status, unmarried status, the presence of > 3 chronic diseases, first consultation at a community health service center, high medical expenses, frequent attendance of the spouses, long-term medication, the use of both traditional Chinese and Western medicine services, and depression. Conclusions This study summarizes the characteristics of older FAs to community health service centers in China and identifies 10 risk factors significantly associated with frequent attendance.
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Affiliation(s)
- Nana Li
- General Practice Department, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Juan Shou
- General Practice Department, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China.
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The Impact of Pharmaceutical Home Care on Medical Utilization for Frequent Users of Outpatient Services in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147336. [PMID: 34299787 PMCID: PMC8303173 DOI: 10.3390/ijerph18147336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/22/2022]
Abstract
Due to the high-accessibility and low-copayment of healthcare system in Taiwan, the clinical visit frequency of people is relatively high, which often leads to an excessively high healthcare expenditure. The aim of this research was to explore the effectiveness of pharmaceutical home care for frequent users of outpatient service and to analyze the impact of pharmaceutical home care on medical utilization. The study was based on the Taiwan National Health Insurance Research Database. Patients with over 100 clinical visits during 2010 to 2012 were selected as subjects. Whether these patients participate the experimental plan of pharmaceutical home care in the following year and the medical utilization of the research subjects were analyzed to compare the difference between participating group and non-participating group in this plan. The generalized estimating equation was employed to examine the difference of medical utilization. A total of 3943 subjects were included in this study, including 591 patients (14.99%) participating in the experimental plan. The average number of physician visits during the following year of the participating group was higher than that of the non-participating group by 0.12 visits, and the outpatient medical expense was lower than the non-participating group by 18,302 points (1 point = 0.03 US dollars). After participating in the plan, the average number of clinical visits of frequent users of outpatient services was significantly reduced by 6.63 visits, and the outpatient expense was significantly decreased by 9871 points. After joining the experimental plan of pharmaceutical home care, the average number of outpatient visits decreased significantly and the medical expense was lower when compared with those who did not participate in the plan.
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Daniels NF, Ridwan R, Barnard EBG, Amanullah TM, Hayhurst C. A comparison of emergency department presentations for medically unexplained symptoms in frequent attenders during COVID-19. Clin Med (Lond) 2021; 21:e399-e402. [PMID: 34016583 DOI: 10.7861/clinmed.2020-1093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Medically unexplained symptoms (MUS) are those with no identified organic aetiology. Our emergency department (ED) perceived an increase in MUS frequency during COVID-19. The primary aim was to compare MUS incidence in frequent attenders (FAs) during COVID-19 and a control period.A retrospective list of FA-MUS presenting to our ED from March to June 2019 (control) and March to June 2020 (during COVID-19) was compared. Fisher's exact test was used to compare binomial proportions; this presented as relative risk (RR) with 95% confidence intervals (95%CI).During COVID-19, ED attendances reduced by 32.7%, with a significant increase in the incidence of FA-MUS and FA-MUS ED visits compared to control; RR 1.5 (95%CI 1.1-1.8) p=0.0006, and RR 1.8 (95%CI 1.6-2.0), p<0.0001, respectively.Despite reduced ED attendances during COVID-19, there was a significant increase in the incidence of FA-MUS patients and corresponding ED visits by this cohort. This presents a challenge to ED clinicians who may feel underprepared to manage these patients effectively.
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Affiliation(s)
| | - Raiiq Ridwan
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ed B G Barnard
- Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Canca-Sánchez JC, García-Mayor S, Morales-Asencio JM, Gómez-Gónzalez AJ, Kaknani-Uttumchandani S, Cuevas Fernández-Gallego M, Lupiáñez-Pérez I, Caro-Bautista J, León-Campos Á. Predictors of health service use by family caregivers of persons with multimorbidity. J Clin Nurs 2021; 30:3045-3051. [PMID: 33899287 DOI: 10.1111/jocn.15814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 10/13/2020] [Accepted: 04/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Informal caregivers of patients with multiple chronic conditions are socially good, promoting the sustainability of a large part of home care provision. However, this very demanding activity causes health problems that increase their own need for health services. This study analyses the use of health services by informal carers, comparing it with the use made by the general population with similar characteristics. METHODOLOGY Cross-sectional analytical study carried out in the Malaga-Valle Guadalhorce Primary Health Care District (Spain). Healthcare demand and perceived health were measured in the family caregivers, compared to the general population. Strobe Statement for observational studies has been used to strength the report of the results. RESULTS Final sample consisted of 314 family caregivers together with a subsample of 2.290 non-caregivers taken from data of the National Health Survey. This subsample was paired by gender with our sample. Formal caregivers make fewer annual visits to the health services, with respect to the general population, regardless of the perceived level of health. The difference of the means between those who perceive their health as very poor was 0.11 (95% CI: 0.01 to 0.20) consultations with the family doctor, 0.21 (95% CI: 0.15 to 0.26) consultations with medical specialists and 1.70 (95% CI: 1.52 to 1.87) emergency room attention. Three independent factors were identified that predispose to the increased use of health services: background of greater education achievement (OR 8.13, 95% CI: 1.30 to 50.68), non-cohabitation with the care recipient (OR 3.57, 95% CI: 1.16 to 11.11) and a more positive physical quality of life component (OR 1.06; 95% CI: 1.03 to 1.09). DISCUSSION AND IMPLICATIONS Intrinsic components of the caregiver reveal their independent relationship with the provision of informal care and the use of health services. A broader vision is needed for the factors that influence the health of these caregivers to develop multipurpose interventions and improve the consistency and effectiveness of the health services offered to the caregiver.
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Affiliation(s)
- José C Canca-Sánchez
- Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,Junta de Andalucía Servicio Andaluz de Salud, Málaga, Spain
| | - Silvia García-Mayor
- Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - José Miguel Morales-Asencio
- Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | | | - Shakira Kaknani-Uttumchandani
- Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Magdalena Cuevas Fernández-Gallego
- Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,Junta de Andalucía Servicio Andaluz de Salud, Málaga, Spain
| | - Inmaculada Lupiáñez-Pérez
- Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,Junta de Andalucía Servicio Andaluz de Salud, Málaga, Spain
| | - Jorge Caro-Bautista
- Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,Junta de Andalucía Servicio Andaluz de Salud, Málaga, Spain
| | - Álvaro León-Campos
- Facultad de Ciencias de la Salud, Universidad de Málaga, Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
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Harish V, Morgado F, Stern AD, Das S. Artificial Intelligence and Clinical Decision Making: The New Nature of Medical Uncertainty. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:31-36. [PMID: 32852320 DOI: 10.1097/acm.0000000000003707] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Estimates in a 1989 study indicated that physicians in the United States were unable to reach a diagnosis that accounted for their patient's symptoms in up to 90% of outpatient patient encounters. Many proponents of artificial intelligence (AI) see the current process of moving from clinical data gathering to medical diagnosis as being limited by human analytic capability and expect AI to be a valuable tool to refine this process. The use of AI fundamentally calls into question the extent to which uncertainty in medical decision making is tolerated. Uncertainty is perceived by some as fundamentally undesirable and thus, for them, optimal decision making should be based on minimizing uncertainty. However, uncertainty cannot be reduced to zero; thus, relative uncertainty can be used as a metric to weigh the likelihood of various diagnoses being correct and the appropriateness of treatments. Here, the authors make the argument, using as examples the experiences of 2 AI systems, IBM Watson on Jeopardy and Watson for Oncology, that medical decision making based on relative uncertainty provides a better lens for understanding the application of AI to medicine than one that minimizes uncertainty. This approach to uncertainty has significant implications for how health care leaders consider the benefits and trade-offs of AI-assisted and AI-driven decision tools and ultimately integrate AI into medical practice.
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Affiliation(s)
- Vinyas Harish
- V. Harish is a fourth-year MD-PhD student, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0001-6364-2439
| | - Felipe Morgado
- F. Morgado is a fourth-year MD-PhD student, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0003-3000-9455
| | - Ariel D Stern
- A.D. Stern is associate professor, Technology and Operations Management Unit, Harvard Business School, Harvard University, Cambridge, Massachusetts; ORCID: https://orcid.org/0000-0002-3586-1041
| | - Sunit Das
- S. Das is associate professor, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0002-2146-4168
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Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R, White P. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020; 24:1-490. [PMID: 32975190 PMCID: PMC7548871 DOI: 10.3310/hta24460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms. OBJECTIVES An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis. DATA SOURCES Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019. PARTICIPANTS Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes. INTERVENTIONS Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes. RESULTS Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000. LIMITATIONS Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points. CONCLUSIONS Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study). STUDY REGISTRATION This study is registered as PROSPERO CRD42015025520. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alison Scope
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London Medical School, London, UK
| | | | - Peter White
- Barts and The London School of Medicine and Dentistry, London, UK
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Gitsels-van der Wal JT, Gitsels LA, Hooker A, Scholing P, Martin L, Feijen-de Jong EI. Perinatal outcomes of frequent attendance in midwifery care in the Netherlands: a retrospective cohort study. BMC Pregnancy Childbirth 2020; 20:269. [PMID: 32375734 PMCID: PMC7201569 DOI: 10.1186/s12884-020-02957-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/20/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Over the last decade, a trend towards high utilisation of primary maternity care was observed in high-income countries. There is limited research with contradictory results regarding frequent attendance (FA) and perinatal outcomes in midwifery care. Therefore, this study examined possible associations between FA in midwifery care and obstetric interventions and perinatal outcomes. METHODS A retrospective cohort study was performed in a medium-sized midwifery-led care practice in an urban region in the Netherlands. Frequent attenders (FAs) were categorised using the Kotelchuck-Index Revised. Regression analyses were executed to examine the relationship between FAs and perinatal outcomes, stratified by antenatal referral to an obstetrician. Main outcomes of interest were Apgar score ≤ 7 and perinatal death, birth weight, mode of delivery, haemorrhage, place of birth, transfer during labour, and a requirement for pain relief. RESULTS The study included 1015 women, 239 (24%) FAs and 776 (76%) non-FAs, 538 (53%) were not referred and 447 (47%) were referred to an obstetrician. In the non-referred group, FA was significantly associated with a requirement for pain relief (OR 1.98, 95% CI 1.24-3.17) and duration of dilatation (OR 1.20, 95% CI 1.04-1.38). In the referred group, FA was significantly associated with induction of labour (OR 1.86, 95% CI 1.17-2.95), ruptured perineum (OR 0.50, 95% CI 0.27-0.95) and episiotomy (OR 0.48, 95% CI 0.24-0.95). In the non-referred and the referred group, FA was not associated with the other obstetric and neonatal outcomes. Due to small numbers, we could not measure possible associations of FA with an Apgar score ≤ 7 and perinatal death. CONCLUSION In our study, perinatal outcomes differed by FA and antenatal referral to an obstetrician. In the non-referred group, FA was significantly associated with medical pain relief and duration of dilatation. In the referred group, FA was significantly associated with induction of labour, ruptured perineum, and episiotomy. Further research with a larger study population is needed to look for a possible association between FA and primary adverse birth outcomes such as perinatal mortality.
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Affiliation(s)
- Janneke T. Gitsels-van der Wal
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081 HV Amsterdam, The Netherlands
| | - Lisanne A. Gitsels
- ESRC funded Business and Local Government Data Research Centre (BLG DRC), School of Computing Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ UK
- University College London, London, UK
| | - Angelo Hooker
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117 Amsterdam, Netherlands
- Zaans Medical Center, Department of Obstetrics and Gynecology, Koningin Julianaplein 58, Zaandam, Netherlands
| | - Paula Scholing
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081 HV Amsterdam, The Netherlands
| | - Linda Martin
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081 HV Amsterdam, The Netherlands
| | - Esther I. Feijen-de Jong
- Amsterdam UMC, Vrije Universiteit Amsterdam, Midwifery Science, AVAG, Amsterdam Public Health research institute, Van der Boechorststraat 7, 1081 HV Amsterdam, The Netherlands
- Department of General Practice & Elderly Medicine, University of Groningen, University Medical Center Groningen, POBox 30001, 9700 RB Groningen, the Netherlands
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10
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Luppa M, Giersdorf J, Riedel-Heller S, Prütz F, Rommel A. Frequent attenders in the German healthcare system: determinants of high utilization of primary care services. Results from the cross-sectional German health interview and examination survey for adults (DEGS). BMC FAMILY PRACTICE 2020; 21:10. [PMID: 31931727 PMCID: PMC6958724 DOI: 10.1186/s12875-020-1082-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 01/08/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND In Germany, patients are consulting general practitioners increasingly frequently, resulting in a high burden on the healthcare system. This study aimed to identify factors associated with frequent primary care attendance in the German healthcare system. METHODS The German Health Interview and Examination Survey for Adults (DEGS) is part of Germany's national health monitoring, and includes a large representative sample of the German population aged 18-79 years. We defined the 10% of participants with the highest number of general practitioner contacts in the preceding 12 months as frequent attenders of primary care services. Binary logistic regression models with average marginal effects were used to identify potential determinants for frequent use of primary care services. RESULTS The sample comprised 7956 participants. Significant effects on frequent use of primary care were observed for low socioeconomic status, stressful life events, factors related to medical need for care such as medically diagnosed chronic conditions and for subjective health. In the full model, the number of non-communicable diseases and subjective health status had the strongest effect on frequent primary care use. We found an interaction effect suggesting that the association between subjective health status and frequent attendance vanishes with a higher number of non-communicable diseases. CONCLUSIONS We observed strong associations between frequent primary care attendance and medical need for care as well as subjective health-related factors. These findings suggest that better coordination of care may be a preferred method to manage health services utilization and to avoid redundant examinations and uncoordinated clinical pathways. Further research is needed to clarify moderating and mediating factors contributing to high utilization of primary care services.
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Affiliation(s)
- Melanie Luppa
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Jan Giersdorf
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Steffi Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
- Department of General Practice, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Franziska Prütz
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Alexander Rommel
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany.
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11
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Harmelink K, Nijhuis-van der Sanden R, Zeegers E, Hullegie W, Van der Wees P, Staal B. Reasons for continuing physiotherapy treatment after a high-intensity physyiotherapy program in patients after total knee arthroplasty: a mixed-methods study. Physiother Theory Pract 2019; 37:1321-1336. [PMID: 31760847 DOI: 10.1080/09593985.2019.1693675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background: Patients after total knee arthroplasty treated with a 10-day high-intensity physiotherapy program in a resort were expected to recover fast without need for a longer physiotherapy treatment period.Objective: To explore the expectations and experiences of patients with total knee arthroplasty following the high-intensity physiotherapy program, including the perceived recovery level at discharge, and reasons for (not) adhering to the given advice at discharge (being either continuing with or refraining from further physiotherapy treatment).Design: A mixed-methods approach: semi-structured interviews were held and were then used to develop items and answer categories for a survey.Methods: Fifteen patients participated in semi-structured interviews, which focused on expectations and experiences related to the total knee arthroplasty and physiotherapy program, the perceived recovery level at the moment of discharge, and the reasons for the advice at discharge (continuing with or refraining from physiotherapy treatment) being followed. A deductive thematic analysis of those interviews was used to develop a survey, which was sent to the total cohort of 60 patients. Logistic regression models were estimated to determine which factors were associated with the continuation of physiotherapy treatment and (not) following the advice. Results: Four themes were identified: (1) confidence of independent recovery; (2) experiencing residual complaints; (3) expecting further improvement of physical fitness; and (4) preferring to be supervised by a healthcare professional. These themes were covered by 14 items in the survey. In total, 55 out of 60 patients completed the survey. Out of 36 patients, 23 continued with physiotherapy treatment despite an adequate level of recovery. Five out of 19 patients, who were advised to continue with physiotherapy treatment, decided to refrain. Advice to continue with physiotherapy treatment was followed more often than advice to refrain from physiotherapy treatment (OR 0.09; 95%CI 0.01-0.85). Reasons for continuing with physiotherapy treatment were residual complaints, the expectation that their physical fitness could be improved and preferring to be supervised by a healthcare professional. In contrast, patients who refrained from physiotherapy, despite being advised to continue, were self-confident that they could do exercises by themselves.Conclusions: A substantial proportion of patients continued with physiotherapy treatment because they expected that a higher level of recovery could be reached. The level of self-confidence to recover on their own seemed to be an important factor in deciding to continue with or refrain from physiotherapy treatment. It would be helpful to focus on self-management skills during the high-intensity physiotherapy program following total knee arthroplasty.
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Affiliation(s)
- Karen Harmelink
- FysioHolland Twente, Enschede, Netherlands.,Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ria Nijhuis-van der Sanden
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Elgun Zeegers
- Department of Orthopedic Surgery, Medisch Spectrum Twente (MST), Enschede, Netherlands
| | - Wim Hullegie
- Fysiotherapie Hullegie and Richter, Enschede, Netherlands
| | - Philip Van der Wees
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Bart Staal
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands.,HAN University of Applied Sciences, Faculty of Health and Social Studies, Research Group Musculoskeletal Rehabilitation, Nijmegen, Netherlands
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12
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Welzel FD, Stein J, Hajek A, König HH, Riedel-Heller SG. Frequent attenders in late life in primary care: a systematic review of European studies. BMC FAMILY PRACTICE 2017; 18:104. [PMID: 29262771 PMCID: PMC5738881 DOI: 10.1186/s12875-017-0700-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 12/13/2017] [Indexed: 12/24/2022]
Abstract
Background High utilization of health care services is a costly phenomenon commonly observed in primary care practices. However, while frequent attendance in primary care has been broadly studied across age groups, aspects of high utilization by elderly patients have not been investigated in detail. The aim of this paper is to provide a systematic review of frequent attendance in primary care among elderly people. Methods We searched five databases (PubMed, PsycINFO, Web of Science, PubPsych, and Cochrane Library) for published papers addressing frequent attendance in primary health care among elderly individuals. Quality of studies was assessed using established criteria for evaluating methodological quality. Results Ten studies met inclusion criteria and were included for detailed analysis. The average number of patients frequently utilizing primary care services varied across studies from 10% to 33% of the elderly samples and subsamples. The definition of frequent attendance across studies differed substantially. The most consistent associations between frequent attendance and old age were found for presence and severity of physical illness. Results on mental disorders and frequent attendance were heterogeneous. Only a few studies have assessed frequent attendance in association with factors such as drug use, social support or sociodemographic aspects; however results were inconsistent. Conclusions Severe ill health and the need for treatment serve as the main drivers of frequent attendance in older adults. As results were scarce and divergent, future studies are needed to provide more information on this topic. Since prior studies have offered only a snapshot of this service use behaviour, a longitudinal approach would be preferable in the future. Electronic supplementary material The online version of this article (10.1186/s12875-017-0700-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Franziska D Welzel
- Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany.
| | - Janine Stein
- Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
| | - André Hajek
- Department of Health Economics and Health Services Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany.,Institute of General Medicine, University of Leipzig, Leipzig, Germany
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13
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Kaylor-Hughes CJ, Rawsthorne M, Coulson NS, Simpson S, Simons L, Guo B, James M, Moran P, Simpson J, Hollis C, Avery AJ, Tata LJ, Williams L, Morriss RK. Direct to Public Peer Support and e-Therapy Program Versus Information to Aid Self-Management of Depression and Anxiety: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2017; 6:e231. [PMID: 29254909 PMCID: PMC5748474 DOI: 10.2196/resprot.8061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/10/2017] [Accepted: 08/21/2017] [Indexed: 11/17/2022] Open
Abstract
Background Regardless of geography or income, effective help for depression and anxiety only reaches a small proportion of those who might benefit from it. The scale of the problem suggests a role for effective, safe, anonymized public health–driven Web-based services such as Big White Wall (BWW), which offer immediate peer support at low cost. Objective Using Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) methodology, the aim of this study was to determine the population reach, effectiveness, cost-effectiveness, and barriers and drivers to implementation of BWW compared with Web-based information compiled by UK’s National Health Service (NHS, NHS Choices Moodzone) in people with probable mild to moderate depression and anxiety disorder. Methods A pragmatic, parallel-group, single-blind randomized controlled trial (RCT) is being conducted using a fully automated trial website in which eligible participants are randomized to receive either 6 months access to BWW or signposted to the NHS Moodzone site. The recruitment of 2200 people to the study will be facilitated by a public health engagement campaign involving general marketing and social media, primary care clinical champions, health care staff, large employers, and third sector groups. People will refer themselves to the study and will be eligible if they are older than 16 years, have probable mild to moderate depression or anxiety disorders, and have access to the Internet. Results The primary outcome will be the Warwick-Edinburgh Mental Well-Being Scale at 6 weeks. We will also explore the reach, maintenance, cost-effectiveness, and barriers and drivers to implementation and possible mechanisms of actions using a range of qualitative and quantitative methods. Conclusions This will be the first fully digital trial of a direct to public online peer support program for common mental disorders. The potential advantages of adding this to current NHS mental health services and the challenges of designing a public health campaign and RCT of two digital interventions using a fully automated digital enrollment and data collection process are considered for people with depression and anxiety. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 12673428; http://www.controlled-trials.com/ISRCTN12673428/12673428 (Archived by WebCite at http://www.webcitation.org/6uw6ZJk5a)
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Affiliation(s)
- Catherine J Kaylor-Hughes
- National Institute for Health Research: Collaboration for Leadership in Applied Health Research and Care East Midlands, University of Nottingham, Nottingham, United Kingdom
| | - Mat Rawsthorne
- National Institute for Health Research: Collaboration for Leadership in Applied Health Research and Care East Midlands, University of Nottingham, Nottingham, United Kingdom
| | - Neil S Coulson
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Sandra Simpson
- Nottinghamshire Healthcare NHS Foundation Trust, Institute of Mental Health, Nottingham, United Kingdom
| | - Lucy Simons
- National Institute for Health Research: MindTech Healthcare Technology Co-operative, Institute of Mental Health, Triumph Road, Nottingham, United Kingdom
| | - Boliang Guo
- National Institute for Health Research: Collaboration for Leadership in Applied Health Research and Care East Midlands, University of Nottingham, Nottingham, United Kingdom
| | - Marilyn James
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Paul Moran
- Centre for Academic Mental Health, School of Social & Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Jayne Simpson
- Nottinghamshire Healthcare NHS Foundation Trust, Institute of Mental Health, Nottingham, United Kingdom
| | - Chris Hollis
- National Institute for Health Research: MindTech Healthcare Technology Co-operative, Institute of Mental Health, Triumph Road, Nottingham, United Kingdom
| | - Anthony J Avery
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Laila J Tata
- Division of Epidemiology & Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Laura Williams
- National Institute for Health Research: Collaboration for Leadership in Applied Health Research and Care East Midlands, University of Nottingham, Nottingham, United Kingdom
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- National Institute for Health Research: Collaboration for Leadership in Applied Health Research and Care East Midlands, University of Nottingham, Nottingham, United Kingdom
| | - Richard K Morriss
- National Institute for Health Research: Collaboration for Leadership in Applied Health Research and Care East Midlands, University of Nottingham, Nottingham, United Kingdom
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14
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Franklin M, Davis S, Horspool M, Kua WS, Julious S. Economic Evaluations Alongside Efficient Study Designs Using Large Observational Datasets: the PLEASANT Trial Case Study. PHARMACOECONOMICS 2017; 35:561-573. [PMID: 28110382 PMCID: PMC5385191 DOI: 10.1007/s40273-016-0484-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Large observational datasets such as Clinical Practice Research Datalink (CPRD) provide opportunities to conduct clinical studies and economic evaluations with efficient designs. OBJECTIVES Our objectives were to report the economic evaluation methodology for a cluster randomised controlled trial (RCT) of a UK NHS-delivered public health intervention for children with asthma that was evaluated using CPRD and describe the impact of this methodology on results. METHODS CPRD identified eligible patients using predefined asthma diagnostic codes and captured 1-year pre- and post-intervention healthcare contacts (August 2012 to July 2014). Quality-adjusted life-years (QALYs) 4 months post-intervention were estimated by assigning utility values to exacerbation-related contacts; a systematic review identified these utility values because preference-based outcome measures were not collected. Bootstrapped costs were evaluated 12 months post-intervention, both with 1-year regression-based baseline adjustment (BA) and without BA (observed). RESULTS Of 12,179 patients recruited, 8190 (intervention 3641; control 4549) were evaluated in the primary analysis, which included patients who received the protocol-defined intervention and for whom CPRD data were available. The intervention's per-patient incremental QALY loss was 0.00017 (bias-corrected and accelerated 95% confidence intervals [BCa 95% CI] -0.00051 to 0.00018) and cost savings were £14.74 (observed; BCa 95% CI -75.86 to 45.19) or £36.07 (BA; BCa 95% CI -77.11 to 9.67), respectively. The probability of cost savings was much higher when accounting for BA versus observed costs due to baseline cost differences between trial arms (96.3 vs. 67.3%, respectively). CONCLUSION Economic evaluations using data from a large observational database without any primary data collection is feasible, informative and potentially efficient. Clinical Trials Registration Number: ISRCTN03000938.
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Affiliation(s)
- Matthew Franklin
- Health Economics and Decision Science (HEDS), ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Sarah Davis
- Health Economics and Decision Science (HEDS), ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Michelle Horspool
- Design, Trials & Statistics (DTS), ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Wei Sun Kua
- Health Economics and Decision Science (HEDS), ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Steven Julious
- Design, Trials & Statistics (DTS), ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
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15
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Goodwin CL, Weisberg RB. Cognitive-behavioural therapy may reduce high rates of service use among frequent primary care attenders. Evid Based Nurs 2017; 20:52. [PMID: 28258063 DOI: 10.1136/eb-2016-102583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Risa B Weisberg
- VA Boston Healthcare System and Boston University School of Medicine, Boston, Massachusetts, USA
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16
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Hajek A, Bock JO, König HH. Association of general psychological factors with frequent attendance in primary care: a population-based cross-sectional observational study. BMC FAMILY PRACTICE 2017; 18:48. [PMID: 28340559 PMCID: PMC5366110 DOI: 10.1186/s12875-017-0621-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 03/20/2017] [Indexed: 11/30/2022]
Abstract
Background Whereas several studies have examined the association between frequent attendance in primary care and illness-specific psychological factors, little is known about the relation between frequent attendance and general psychological factors. Thus, the aim of this study was to investigate the association between being a frequent attender in primary care and general psychological factors. Methods Data were used from a large, population-based sample of community-dwelling individuals aged 40 and above in Germany in 2014 (n = 7,446). Positive and negative affect, life satisfaction, optimism, self-esteem, self-efficacy, and self-regulation were included as general psychological factors. The number of self-reported GP visits in the past twelve months was used to quantify frequency of attendance; individuals with more than 9 visits (highest decile) were defined as frequent attenders. Results Multiple logistic regressions showed that being a frequent attender was positively associated with less life satisfaction [OR: 0.79 (0.70–0.89)], higher negative affect [OR: 1.38 (1.17–1.62)], less self-efficacy [OR: 0.74 (0.63–0.86)], less self-esteem [OR: 0.65 (0.54–0.79)], less self-regulation [OR: 0.74 (0.60–0.91)], and higher perceived stress [OR: 1.46 (1.28–1.66)], after adjusting for sociodemographic factors, morbidity and lifestyle factors. However, frequent attendance was not significantly associated with positive affect and self-regulation. Conclusions The present study highlights the association between general psychological factors and frequent attendance. As frequent GP visits produce high health care costs and are potentially associated with increased referrals and use of secondary health care services, this knowledge might help to address these individuals with high needs. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0621-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- André Hajek
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jens-Oliver Bock
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lee K, Johnson MH, Harris J, Sundram F. The resource utilisation of medically unexplained physical symptoms. SAGE Open Med 2016; 4:2050312116666217. [PMID: 27635250 PMCID: PMC5011389 DOI: 10.1177/2050312116666217] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/26/2016] [Indexed: 12/31/2022] Open
Abstract
Objectives: As patients with medically unexplained physical symptoms may present frequently to hospital settings and receive potentially unnecessary investigations and treatments, we aimed to assess the frequency and type of medically unexplained physical symptoms presentations to clinical services and estimate the associated direct healthcare costs. Methods: This study was undertaken at the largest district health board in New Zealand. All patients with a diagnosed presentation of medically unexplained physical symptoms in 2013 were identified using the district health board’s clinical coding system. The clinical records (medical and psychiatric) of 49 patients were examined in detail to extricate all medically unexplained physical symptoms–related secondary care activity within 6 months before or after their medically unexplained physical symptoms presentation. Standardised national costing methodology was used to calculate the associated healthcare costs. Results: In all, 49% of patients attended hospital settings at least twice during 2013. The majority of presentations were for neurological or respiratory concerns. The total cost for the sample was GBP89,636 (median: GBP1,221). Costs were most significant in the areas of inpatient admissions and emergency care. Conclusion: Medically unexplained physical symptoms result in frequent presentations to hospital settings. The costs incurred are substantial and comparable to the costs of chronic medical conditions with identifiable pathology. Improving recognition and management of medically unexplained physical symptoms has potential to offer more appropriate and cost-effective healthcare outcomes.
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Affiliation(s)
| | - Malcolm H Johnson
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Julie Harris
- Decision Support, Waitemata District Health Board, Auckland, New Zealand
| | - Frederick Sundram
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Cognitive behaviour therapy for long-term frequent attenders in primary care: a feasibility case series and treatment development study. Br J Gen Pract 2016; 66:e729-36. [PMID: 27432609 DOI: 10.3399/bjgp16x686569] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/20/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Most frequent attendance in primary care is temporary. Long-term frequent attendance may be suitable for psychological intervention to address health management and service use. AIM To explore the feasibility and acceptability of cognitive behaviour therapy (CBT) for long-term frequent attendance in primary care and obtain preliminary evidence regarding clinical and cost effectiveness. DESIGN AND SETTING A CBT case series was carried out in five GP practices in the East Midlands. METHOD Frequent attenders (FAs) were identified from case notes and invited by their practice for assessment, then offered CBT. Feasibility and acceptability were assessed by CBT session attendance and thematic analysis of semi-structured questionnaires. Clinical and cost effectiveness was assessed by primary care use and clinically important change on a range of health and quality of life instruments. RESULTS Of 462 FAs invited to interview, 87 (19%) consented to assessment. Thirty-two (7%) undertook CBT over a median of 3 months. Twenty-four (75%) attended at least six sessions. Eighteen FAs (86%, n = 21) reported overall satisfaction with treatment. Patients reported valuing listening without judgement alongside support to develop coping strategies. Thirteen (54%, n = 24), achieved clinically important improvement on the SF-36 Mental-Component Scale at 6-month follow-up and improved quality of life, but no improvement on other outcomes. Primary care use reduced from a median of eight contacts in 3 months at baseline (n = 32) to three contacts in 3 months at 1 year (n = 18). CONCLUSION CBT appears feasible and acceptable to a subset of long-term FAs in primary care who halved their primary care use. With improved recruitment strategies, this approach could contribute to decreasing GP workload and merits larger-scale evaluation.
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Parejo Maestre N, Lendínez-de la Cruz J, Bermúdez-Torres F, Gónzalez-Contero L, Gutierrez-Espinosa de los Monteros M, Espejo-Almazán María T. Prevalencia y factores asociados a la hiperfrecuentación en la consulta de medicina de familia. Semergen 2016; 42:216-24. [DOI: 10.1016/j.semerg.2015.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 03/03/2015] [Accepted: 05/13/2015] [Indexed: 10/23/2022]
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20
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van den Bussche H, Kaduszkiewicz H, Schäfer I, Koller D, Hansen H, Scherer M, Schön G. Overutilization of ambulatory medical care in the elderly German population?--An empirical study based on national insurance claims data and a review of foreign studies. BMC Health Serv Res 2016; 16:129. [PMID: 27074709 PMCID: PMC4831189 DOI: 10.1186/s12913-016-1357-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 03/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND By definition, high utilizers receive a large proportion of medical services and produce relatively high costs. The authors report the results of a study on the utilization of ambulatory medical care by the elderly population in Germany in comparison to other OECD countries. Evidence points to an excessive utilization in Germany. It is important to document these utilization figures and compare them to those in other countries since the healthcare system in Germany stopped recording ambulatory healthcare utilization figures in 2008. METHODS The study is based on the claims data of all insurants aged ≥ 65 of a statutory health insurance company in Germany (n = 123,224). Utilization was analyzed by the number of contacts with physicians in ambulatory medical care and by the number of different practices contacted over one year. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 different practices or ≥ 3 practices of the same discipline per year. Descriptive statistical analysis and logistic regression were applied. Morbidity was analyzed by prevalence and relative risk for frequent attendance for 46 chronic diseases. RESULTS Nineteen percent of the elderly were identified as high utilizers, corresponding to approximately 3.5 million elderly people in Germany. Two main types were identified. One type has many contacts with practices, belongs to the oldest age group, suffers from severe somatic diseases and multimorbidity, and/or is dependent on long-term care. The other type contacts large numbers of practices, consists of younger elderly who often suffer from psychiatric and/or psychosomatic complaints, and is less frequently multimorbid and/or nursing care dependent. CONCLUSION We found a very high rate of frequent attendance among the German elderly, which is unique among the OECD countries. Further research should clarify its reasons and if this degree of utilization is beneficial for elderly people.
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Affiliation(s)
- Hendrik van den Bussche
- Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Hanna Kaduszkiewicz
- Institute of General Practice, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Ingmar Schäfer
- Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Daniela Koller
- Department of Health Services Management, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Heike Hansen
- Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Martin Scherer
- Institute of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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Hastings A, Fowler J, Morriss R, Scanlan M, Smart D, Valand R, Waseem Shahzad M. The development of a short course for general practitioners in the management of patients with medically unexplained symptoms (MUS). EDUCATION FOR PRIMARY CARE 2016; 27:53-6. [PMID: 26862800 DOI: 10.1080/14739879.2015.1119978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Adrian Hastings
- a Department of Medical and Social Care Education , University of Leicester , Leicester , UK
| | - John Fowler
- b Independent Researcher and Education Consultant , Leicester , UK
| | | | | | - David Smart
- e General Practitioner Partner , Northampton , UK
| | - Reena Valand
- f Innovation and Improvement, Health Education , East Midlands , UK
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Patel S, Malins S, Guo B, James M, Kai J, Kaylor-Hughes C, Rowley E, Simpson J, Smart D, Stubley M, Tyrer H, Morriss R. Protocol investigating the clinical outcomes and cost-effectiveness of cognitive-behavioural therapy delivered remotely for unscheduled care users with health anxiety: randomised controlled trial. BJPsych Open 2016; 2:81-87. [PMID: 27703758 PMCID: PMC4995569 DOI: 10.1192/bjpo.bp.115.002220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/10/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Health anxiety and medically unexplained symptoms cost the National Health Service (NHS) an estimated £3 billion per year in unnecessary costs with little evidence of patient benefit. Effective treatment is rarely taken up due to issues such as stigma or previous negative experiences with mental health services. An approach to overcome this might be to offer remotely delivered psychological therapy, which can be just as effective as face-to-face therapy and may be more accessible and suitable. AIMS To investigate the clinical outcomes and cost-effectiveness of remotely delivered cognitive-behavioural therapy (CBT) to people with high health anxiety repeatedly accessing unscheduled care (trial registration: NCT02298036). METHOD A multicentre randomised controlled trial (RCT) will be undertaken in primary and secondary care providers of unscheduled care across the East Midlands. One hundred and forty-four eligible participants will be equally randomised to receive either remote CBT (6-12 sessions) or treatment as usual (TAU). Two doctoral research studies will investigate the barriers and facilitators to delivering the intervention and the factors contributing to the optimisation of therapeutic outcome. RESULTS This trial will be the first to test the clinical outcomes and cost-effectiveness of remotely delivered CBT for the treatment of high health anxiety. CONCLUSIONS The findings will enable an understanding as to how this intervention might fit into a wider care pathway to enhance patient experience of care. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
| | | | - Boliang Guo
- , PhD, Collaboration for Leadership in Applied Health Research and Care (CLAHRC)
| | | | - Joe Kai
- , MD, FRCGP, Faculty of Medicine & Health Sciences
| | | | | | | | - David Smart
- , MB ChB, MRCGP, Leicester Terrace Health Care Centre, Northampton
| | | | - Helen Tyrer
- , PhD, Department of Medicine, Imperial College London, London
| | - Richard Morriss
- , MD, FRCPsych, CLAHRC, University of Nottingham, Nottingham, UK
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Patel S, Kai J, Atha C, Avery A, Guo B, James M, Malins S, Sampson C, Stubley M, Morriss R. Clinical characteristics of persistent frequent attenders in primary care: case-control study. Fam Pract 2015; 32:624-30. [PMID: 26450918 PMCID: PMC5926457 DOI: 10.1093/fampra/cmv076] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Most frequent attendance in primary care is temporary, but persistent frequent attendance is expensive and may be suitable for psychological intervention. To plan appropriate intervention and service delivery, there is a need for research involving standardized psychiatric interviews with assessment of physical health and health status. OBJECTIVE To compare the mental and physical health characteristics and health status of persistent frequent attenders (FAs) in primary care, currently and over the preceding 2 years, with normal attenders (NAs) matched by age, gender and general practice. METHODS Case-control study of 71 FAs (30 or more GP or practice nurse consultations in 2 years) and 71 NAs, drawn from five primary care practices, employing standardized psychiatric interview, quality of life, health anxiety and primary care electronic record review over the preceding 2 years. RESULTS Compared to NAs, FAs were more likely to report a lower quality of life (P < 0.001), be unmarried (P = 0.03) and have no educational qualifications (P = 0.009) but did not differ in employment status. FAs experienced greater health anxiety (P < 0.001), morbid obesity (P = 0.02), pain (P < 0.001) and long-term pathological and ill-defined physical conditions (P < 0.001). FAs had more depression including dysthymia, anxiety and somatoform disorders (all P < 0.001). CONCLUSIONS Persistent frequent attendance in primary care was associated with poor quality of life and high clinical complexity characterized by diverse and often persistent physical and mental multimorbidity. A brokerage model with GPs working in close liaison with skilled psychological therapists is required to manage such persistent complexity.
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Affiliation(s)
- Shireen Patel
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Joe Kai
- Division of Primary Care and
| | - Christopher Atha
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | | | - Boliang Guo
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Marilyn James
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Samuel Malins
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Christopher Sampson
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Michelle Stubley
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Richard Morriss
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands,
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Smits FT, Brouwer HJ, Zwinderman AH, Mohrs J, Schene AH, van Weert HCPM, ter Riet G. Why do they keep coming back? Psychosocial etiology of persistence of frequent attendance in primary care: a prospective cohort study. J Psychosom Res 2014; 77:492-503. [PMID: 25217448 DOI: 10.1016/j.jpsychores.2014.08.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 07/21/2014] [Accepted: 08/12/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients who visit their General Practitioner (GP) very frequently over extended periods of time often have multimorbidity and are costly in primary and specialist healthcare. We investigated the impact of patient-level psychosocial and GP-level factors on the persistence of frequent attendance (FA) in primary care. METHODS Two-year prospective cohort study in 623 incident adult frequent attenders (>90th attendance centile; age and sex-adjusted) in 2009. Information was collected through questionnaires (patients, GPs) and GPs' patient data. We used multilevel, ordinal logistic regression analysis, controlling for somatic illness and demographic factors with FA in 2010 and/or 2011 as the outcome. RESULTS Other anxiety (odds ratio (OR) 2.00; 95% confidence interval from 1.29 to 3.10) over 3years and the number of life events in 3years (OR 1.06; 1.01-1.10 per event; range of 0 to 12) and, at baseline, panic disorder (OR 5.40; 1.67-17.48), other anxiety (OR 2.78; 1.04-7.46), illness behavior (OR 1.13; 1.05-1.20 per point; 28-point scale) and lack of mastery (OR 1.08; 1.01-1.15 per point; 28-point scale) were associated with persistence of FA. We found no evidence of synergistic effects of somatic, psychological and social problems. We found no strong evidence of effects of GP characteristics. CONCLUSION Panic disorder, other anxiety, negative life events, illness behavior and lack of mastery are independently associated with persistence of frequent attendance. Effective intervention at these factors, apart from their intrinsic benefits to these patients, may reduce attendance rates, and healthcare expenditures in primary and specialist care.
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Affiliation(s)
- Frans T Smits
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands.
| | - Henk J Brouwer
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Jacob Mohrs
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Aart H Schene
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands; Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk C P M van Weert
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
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Diaz E, Gimeno-Feliu LA, Calderón-Larrañaga A, Prados-Torres A. Frequent attenders in general practice and immigrant status in Norway: a nationwide cross-sectional study. Scand J Prim Health Care 2014; 32:232-40. [PMID: 25421090 PMCID: PMC4278396 DOI: 10.3109/02813432.2014.982368] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the likelihood of being a frequent attender (FA) to general practice among native Norwegians and immigrants, and to study socioeconomic and morbidity factors associated with being a FA for natives and immigrants. DESIGN, SETTING AND SUBJECTS Linked register data for all inhabitants in Norway with at least one visit to the general practitioner (GP) in 2008 (2 967 933 persons). Immigrants were grouped according to their country of origin into low- (LIC), middle- (MIC), and high-income countries (HIC). FAs were defined as patients whose attendance rate ranked in the top 10% (cut-off point > 7 visits). MAIN OUTCOME MEASURES FAs were compared with other GP users by means of multivariate binary logistic analyses adjusting for socioeconomic and morbidity factors. RESULTS Among GP users during the daytime, immigrants had a higher likelihood of being a FA compared with natives (OR (95% CI): 1.13 (1.09-1.17) and 1.15 (1.12-1.18) for HIC, 1.84 (1.78-1.89) and 1.66 (1.63-1.70) for MIC, and 1.77 (1.67-1.89) and 1.65 (1.57-1.74) for LIC for men and women respectively). Pregnancy, middle income earned in Norway, and having cardiologic and psychiatric problems were the main factors associated with being a FA. Among immigrants, labour immigrants and the elderly used GPs less often, while refugees were overrepresented among FAs. Psychiatric, gastroenterological, endocrine, and non-specific drug morbidity were relatively more prevalent among immigrant FA compared with natives. CONCLUSION Although immigrants account for a small percentage of all FAs, GPs and policy-makers should be aware of differences in socioeconomic and morbidity profiles to provide equality of health care.
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Affiliation(s)
- Esperanza Diaz
- Department of Global Public Health and Primary Care, University of Bergen, Norway
- Norwegian Centre for Minority Health Research, Norway
| | - Luis-Andrés Gimeno-Feliu
- EpiChron Research Group on Chronic Diseases, Aragón Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, Spain
- San Pablo Health Centre, Zaragoza, Spain
- University of Zaragoza, Spain
| | - Amaia Calderón-Larrañaga
- EpiChron Research Group on Chronic Diseases, Aragón Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, Spain
- University of Zaragoza, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Carlos III Health Institute, Madrid, Spain
| | - Alexandra Prados-Torres
- EpiChron Research Group on Chronic Diseases, Aragón Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, Spain
- University of Zaragoza, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Carlos III Health Institute, Madrid, Spain
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Lau K, Löwe B, Langs G, Voigt K. Aus vier mach zwei. PSYCHOTHERAPEUT 2013. [DOI: 10.1007/s00278-013-1019-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hauswaldt J, Himmel W, Hummers-Pradier E. The inter-contact interval: a new measure to define frequent attenders in primary care. BMC FAMILY PRACTICE 2013; 14:162. [PMID: 24152427 PMCID: PMC3834877 DOI: 10.1186/1471-2296-14-162] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 10/10/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Frequent attenders receive much attention in primary care research. Defining frequent attendance is crucial for an adequate view on this group of demanding patients. We aimed to develop a purely contact-based definition of "frequent attendance" and to apply it to real patients. METHODS From electronic records of 123 general practices in Germany, patients' inter-contact intervals (ICI) between two consecutive doctor-patient-contacts were calculated in this retrospective observational study. ICI less than 7 days were labelled "frequent attendance", patients with 60% or more of such intervals "frequent attenders (new view)". In contrast, patients having at least 24 contacts per calendar year were considered "frequent attenders (traditional view)". Both groups were analysed in their diseases and demands, using multiple logistic regression. RESULTS A total of 177,057 patients with at least 3 ICI in 1996 until 2006 yielded 4,408,033 ICI. One third were "short" ICI (less than 7 days), resulting in 19,759 (11.2%) frequent attenders (new). In contrast, 22,921 (12.9%) patients were frequent attenders (traditional). Compared to non-frequent attenders, frequent attenders (new) were more likely to have pneumonia (OR 1.66), stroke (OR 1.49), dementia (OR 1.46), or severe substance abuse (OR 1.44), also to need home visits or emergency attention. Frequent attenders (traditional) were more likely to have dementia (OR 2.76) or stroke (OR 2.06), and by far to need home visits (OR 5.43; all p < 0.001). CONCLUSIONS A new measure, the interval in days of two consecutive face-to-face contacts (ICI), widens our perspective on frequent attenders in general practice. In many cases, their consultation behaviour and need for medical services seem to follow "disease logic".
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Affiliation(s)
- Johannes Hauswaldt
- Department of General Practice/Family Medicine, University Medical Centre, Georg-August-University, Humboldtallee 38, 37073 Göttingen, Germany.
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van den Bussche H, Niemann D, Kaduszkiewicz H, Schäfer I, Koller D, Hansen H, Scherer M, Glaeske G, Schön G. [Which chronic diseases are associated with frequent attending of ambulatory medical care in the elderly population in Germany? - A study based on statutory health insurance data]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2013; 107:442-50. [PMID: 24238021 DOI: 10.1016/j.zefq.2013.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 07/29/2013] [Accepted: 09/10/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Frequent attenders utilise a high proportion of medical services and therefore produce relatively high costs. Questions of utility and adequacy and, also, about the reasons for high use arise. The authors report the results of a study on the association between morbidity of the elderly and various forms of frequent attendance in ambulatory medical care in Germany. METHODS The study is based on claims data of all policyholders aged 65 and over of a statutory health insurance company operating nationwide in Germany in 2004 (n = 123,224). Utilisation was analysed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different practices contacted. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 individual practices or ≥ 3 practices of the same discipline per year. We analysed prevalences and relative risks for frequent attendance for 46 chronic diseases. RESULTS Frequent attendance in ambulatory medical care among the elderly is related to both severe somatic and psychic diagnoses. Five chronic diseases showed the highest relative risks for all types of frequent attendance in general: urinary incontinence, anaemia, neuropathies, renal insufficiency, and cancer. Psychic syndromes mainly led to the utilisation of many different physicians. CONCLUSION Frequent attendance in ambulatory medical care among the elderly is related to a large number of diseases, both somatic and psychic. Frequent attendance is a complex phenomenon which cannot be addressed by mono-dimensional approaches.
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Smits FT, Brouwer HJ, Zwinderman AH, Mohrs J, Smeets HM, Bosmans JE, Schene AH, Van Weert HC, ter Riet G. Morbidity and doctor characteristics only partly explain the substantial healthcare expenditures of frequent attenders: a record linkage study between patient data and reimbursements data. BMC FAMILY PRACTICE 2013; 14:138. [PMID: 24044374 PMCID: PMC3851974 DOI: 10.1186/1471-2296-14-138] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 09/06/2013] [Indexed: 11/29/2022]
Abstract
Background Frequently attending patients to primary care (FA) are likely to cost more in primary care than their non-frequently attending counterparts. But how much is spent on specialist care of FAs? We describe the healthcare expenditures of frequently attending patients during 1, 2 or 3 years and test the hypothesis that additional costs can be explained by FAs’ combined morbidity and primary care physicians’ characteristics. Methods Record linkage study. Pseudonymised clinical data from the medical records of 16 531 patients from 39 general practices were linked to healthcare insurer’s reimbursements data. Main outcome measures were all reimbursed primary and specialist healthcare costs between 2007 and 2009. Multilevel linear regression analysis was used to quantify the effects of the different durations of frequent attendance on three-year total healthcare expenditures in primary and specialist care, while adjusting for age, sex, morbidities and for primary care physicians characteristics. Primary care physicians’ characteristics were collected through administrative data and a questionnaire. Results Unadjusted mean 3-year expenditures were 5044 and 15 824 Euros for non-FAs and three-year-FAs, respectively. After adjustment for all other included confounders, costs both in primary and specialist care remained substantially higher and increased with longer duration of frequent attendance. As compared to non-FAs, adjusted mean expenditures were 1723 and 5293 Euros higher for one-year and three-year FAs, respectively. Conclusions FAs of primary care give rise to substantial costs not only in primary, but also in specialist care that cannot be explained by their multimorbidity. Primary care physicians’ working styles appear not to explain these excess costs. The mechanisms behind this excess expenditure remain to be elucidated.
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Affiliation(s)
- Frans T Smits
- Department of General Practice - Academic Medical Center, University of Amsterdam, Amsterdam 1105 AZ, The Netherlands.
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Wiklund-Gustin L. Struggling on my own: a cognitive perspective on frequent attenders' conception of life and their interaction with the healthcare system. PSYCHIATRY JOURNAL 2013; 2013:580175. [PMID: 24236283 PMCID: PMC3820073 DOI: 10.1155/2013/580175] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Revised: 03/11/2013] [Accepted: 03/26/2013] [Indexed: 11/25/2022]
Abstract
Different studies reveal that a large percentage of people frequently attending healthcare not only suffer from diffuse somatic symptoms but also from psychological distress and difficulties in dealing with everyday life. Even though they are not always diagnosed with psychiatric disease, questions arise about their mental health. The study aims at describing frequent attenders' conceptions of life, and as a result their health, from a cognitive perspective. A qualitative content analysis of in-depth interviews was carried out with nine service users in primary healthcare. The findings reveal that participants experience themselves as inadequate and as being a burden for others, by whom they experience rejection, in different ways. In order to take part in community with others the person develops compensatory strategies that aim at concealing their inadequacies, thus also preventing them from sharing their suffering with others. The consequence is that the persons become even more alienated as they start to relate to others through a façade and furthermore are unable to either improve their health or obtain adequate care. It can be concluded that these patients need to be taken seriously in order to prevent further psychological suffering.
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Affiliation(s)
- Lena Wiklund-Gustin
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23 Västerås, Sweden
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